Journal of Indian Society of Periodontology

: 2018  |  Volume : 22  |  Issue : 6  |  Page : 541--545

Awareness among intensive care nurses regarding oral care in critically ill patients

Vidya Priyadharshini Doddasomanahalli Sreenivasan1, Aruna Ganganna1, Premalatha Bidadi Rajashekaraiah2,  
1 Department of Periodontology, JSS Dental College and Hospital, Jagadguru Shri Shivarathreeshwara University, Mysuru, Karnataka, India
2 Department of Oral Pathology and Microbiology, JSS Dental College and Hospital, Jagadguru Shri Shivarathreeshwara University, Mysuru, Karnataka, India

Correspondence Address:
Dr. Vidya Priyadharshini Doddasomanahalli Sreenivasan
Department of Periodontology, JSS Dental College and Hospital, Jagadguru Shri Shivarathreeshwara University, Mysuru - 570 015, Karnataka


Background: Oral health and general health are interdependent which influence each other through biological, psychological, emotional, and developmental factors. As patients in Intensive Care Unit (ICU) are completely dependent on the caregivers, the knowledge, attitude, and practices of the nurses influence the recovery of patients to a greater extent. Objectives: Unfortunately, oral health problems are usually overshadowed by other serious needs in critically ill patients. In addition, nursing staff appear to perceive oral health as the most difficult part of their work, hence been a low-priority intervention. Therefore, the aim of the study was to assess the knowledge, attitude, and practices of ICU nurses on oral care in critically ill patients. Materials and Methods: A total of 200 nurses working in 21 different hospitals in Mysore, Karnataka, participated in the cross-sectional survey. The survey instrument included the demographic details, knowledge, attitude, and practice of oral care, complications in ICU due to lack of oral care, and educative programs attended. Results: Among the 200 ICU nurses, 67% had ICU experience of more than 5 years. About 94% were diploma candidates, 5% were graduates, and only 2% were postgraduates with a mean age of 27.5 years. All the participants were aware of the concept of focal infection theory and 93% knew about the potential complications associated with poor oral hygiene in ICU. About 95.5% of the nurses performed oral care after every shift change and used gauze soaked in chlorhexidine routinely. Nearly 76.5% of the participants stated mechanical obstruction as a main barrier toward oral care. Conclusion: A variety of oral care practices exist for ventilated patients but, the majority of nurses used chlorhexidine with gauze. They failed to adhere to the latest evidence-based practice despite ranking oral care as a high priority. They need to be educated to improve clinical outcomes thereby reducing the hospital mortality and stay in ICU.

How to cite this article:
Sreenivasan VP, Ganganna A, Rajashekaraiah PB. Awareness among intensive care nurses regarding oral care in critically ill patients.J Indian Soc Periodontol 2018;22:541-545

How to cite this URL:
Sreenivasan VP, Ganganna A, Rajashekaraiah PB. Awareness among intensive care nurses regarding oral care in critically ill patients. J Indian Soc Periodontol [serial online] 2018 [cited 2020 Jul 5 ];22:541-545
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Full Text


Oral care is recognized as an essential component of care for critically ill patients which provides comfort and enhances a sense of wellbeing. Oral and general health are interdependent which influence each other through biological, psychological, emotional, and developmental factors.[1] As the patients in Intensive Care Unit (ICU) completely depend on the caregivers; the knowledge, attitude, and practices followed by the nurses influence the recovery of patients to a great extent. Unfortunately, oral health problems are usually overshadowed by other serious needs in critically ill patients. In addition, nursing staff appear to perceive oral health as the most difficult part of their work; hence, it has been a low-priority intervention.[2] If the nurses are to appreciate the importance of oral health, they must have a clear understanding of the complex characteristics of bacterial colonization in the oropharynx leading to systemic diseases such as cardiovascular disease,[3] chronic obstructive pulmonary disease,[4] and ventilator-associated pneumonia (VAP) in critically ill patients.[5],[6]

VAP is a hospital-acquired pneumonia that occurs between 48-72 h, among endotracheally intubated and mechanically ventilated patients.[7] Among the nosocomial infections, VAP is the second common cause for morbidity and the first for mortality which leads to increased hospital stay and billions of dollars spent toward health-care in the United States.[8]

Surveys conducted in Europe and the United States have reported that majority of the nurses considered oral care as an important nursing activity but varied with the frequency, methods employed and requisites used for oral care.[9] A national survey conducted in Israel showed that nurses failed to implement the latest evidence-based knowledge regarding oral care conversely, Jones et al. stated that the methods followed by the nurses were appropriate and evidence based.[10],[11] To date, no data is available on the local empirical knowledge and the practices of ICU nurses in India. Therefore, this survey targeted the nurses, as patients in ICU have a predisposition to develop complications such as VAP.

 Materials and Methods

This cross-sectional survey was conducted in randomly selected ICU nurses for 6 months from January 2014 to June 2014. A total of 200 nurses, from medical (112) and surgical (88) ICUs were selected to participate in the study working in 21 different hospitals in Mysore, Karnataka. The sample size was estimated using nMasters software (Department of Biostatistics, CMC, Vellore, Tamil Nadu, India). The sample size was computed to be 165 based on estimating single proportion at an expected proportion of 0.7 at 10% relative precision and 95% confidence level. However, the sample size was rounded off to 200 anticipating 20% nonresponse. Permission to conduct the survey was obtained from the Institutional Ethical Committee and also from the respective administrative departments of the hospitals.

In the first visit, two researchers approached the managerial staff or the nursing superintendents with a questionnaire. The researchers made no attempt to meet the nurses participating in the study to avoid interactions or exchange of views. The second visit was scheduled 3–4 days after the first and the survey forms were collected directly from the nurses. Written consent was taken before the survey from the nurses who volunteered to participate. Feedback regarding the survey, their opinion on oral hygiene practices, and the protocol followed was obtained in a short discussion after receiving the survey forms.

The questionnaire had the following sections:

Part A - The demographic details listing the age, sex, highest nursing education, specialty of service, years of nursing experience, and their services in ICUPart B - Questions regarding the attitude and knowledge of nurses toward the oral hygiene in critically ill ICU patientsPart C - Clinical practices in ICU.

Three of the questions in Part B were to be answered in YES or NO format and the rest were multiple choice questions. The additional space was provided at the end of each question to furnish extra details by the participants if required.

Validity which denotes the truthfulness and accuracy of the instrument was measured by handing the final questionnaire to a sample of 30 respondents. Potential problems were evaluated by encouraging questions from the respondents; questions raised by the respondents indicated a defective item which was fixed later. An expert (other than the two principal investigators) who understood the topic read-through the questions to check whether they captured the topic under investigation and ruled out confusing, double-barrelled, and leading questions.[12] Finally, the internal consistency of the questions was measured by calculating the Cronbach's Alpha which ranged from 0.6 to 0.8.1.


Among the 200 ICU nurses, 62 were male and 138 were female with the mean age of 28 and 29.058, respectively [Table 1]. All the respondents were registered nurses possessing diploma (94%), baccalaureate (5%), and postgraduate degree (1%). All the participating nurses were aware of “Focal theory of infection” and followed the protocol specified by their respective hospital. About 93% of the nurses were aware of the potential complications associated with poor oral hygiene, but only 18% of them specifically answered the questions related to VAP and its relative consequences [Table 2]a and [Table 2]b.{Table 1}{Table 2}

Shift change was programmed every 6 h (86% of the hospitals), and about 95% of the nurses performed oral care after every change in shift using a wide range of oral decontamination procedures as no written, standard guidelines existed. About 91.5% of the nurses used gauze soaked in chlorhexidine, 2% used toothpaste and brush, 3.5% used normal saline, and 3% used hydrogen peroxide for plaque removal [Table 3].{Table 3}

Mann–Whitney test was carried to know the knowledge levels among nurses with more than 5 years and < 5 years of experience which was not statistically significant [Table 4]. ANOVA was carried out to test knowledge levels among the nurses who possessed diploma, graduate, and postgraduate degree which showed no significant difference among the groups [Table 5].{Table 4}{Table 5}


India, being a developing country, lags far behind developed nations in the health arena with long-standing challenges. The data available indicate that the burden of hospital-associated infection is high, with an estimated pooled prevalence of 15.5/100 patients, more than double the prevalence in Europe and the US. Although in India, private sectors and academic hospitals have participated in surveillance/survey through the International Nosocomial Infection Control Consortium to provide data on incidence, the findings have not led to a broader policy change in infection prevention and control.[13]

Critically ill patients in the ICU are associated with increased morbidity, mortality, and hospital care costs as patients are immunocompromised and at a high risk for infections. The overall infection rate may be as high as 50%–60% in patients who remain in ICU for more than 5 days and incidence of VAP may range from 10% to 65% which could be a prime concern in ICU.[14] Hence, a thorough understanding of the pathogenesis is fundamental among the hospital-care givers as critically ill patients are dependent on them for clinical care.

There is convincing evidence that biofilms formed on the oral surface and endotracheal tubes act as a reservoir of organisms that cause VAP therefore, oropharyngeal decontamination, and other strategies aimed at preventing this translocation must be emphasized.[15],[16] Surprisingly, no uniform method or protocol exists, and nurses usually practice traditional techniques which are ineffective and also fail to document them.

Ventilator bundle, as proposed by Centers for Disease Control and Prevention along with the American Association of Critical Care nurses includes elevating the head end of the bed, continuous subglottic suctioning, changing ventilator circuit within 48 h, washing hands before and after patient contact.[17] However, these guidelines do not recommend oral care which is otherwise considered pivotal in patient care. Considering this drawback and supported in parallel by current scientific evidence, this clinical project aimed to know the knowledge, attitude, and practices of nurses treating critically ill patients in ICU.

In healthy volunteers, Pearson reported that foam swabs were less effective in plaque removal than tooth brushing and noted that the efficacy of foam swabs depended on user's technique.[18] Nurses in this survey indicated the frequent use of gauze soaked with chlorhexidine mouth rinse, only 2% reported the use of toothbrush with a dentifrice despite the fact, that toothbrushes are more effective in plaque removal and gingival stimulation. This could be compared to Jordanian critical care nurses practices, where none of the nurses brushed the patients' teeth. This could be attributed to tooth brushing not being incorporated in the protocol, unavailability of supplies or lack of time.[19] The American Association of Critical Care Nurses Endotracheal Tube and Oral Care procedure offers the most evidence-based protocol for oral care to be used by health-care providers.[20] It strongly suggested the use of pediatric or adult (soft) toothbrush at least twice a day. To ensure the best removal of secretions and minimize the aspirations, suctioning the oral cavity before and after oral care was highlighted. In addition, oral swab with 1.5% H2O2 solution should be used to clean mouth every 2–4 h.

The shift of duty was programmed every 6 h (86% of the hospitals) and about 95% of the nurses performed oral care after every change in shift. Grap et al. found nurses are likely to report providing more care than what they actually did. They discovered that 75% of 77 nurses claimed providing oral care five times per day or more for the intubated patients.[21]

Although nurses valued their contribution toward patients' health, they were hesitant to provide oral care in intubated patients due to the fear of tube dislodgement and lack of cooperation. Overall, the mechanical obstruction was reported as a major barrier toward oral care (76.5%). Fear of dislodging or displacing the endotracheal tube is a real concern and can be life-threatening.[22],[23],[24] The insufficient staff which leads to reduced patient-nurse contact time is also considered as an important factor in providing quality health care. When nurses are overburdened, oral care is often the first practice to be deferred.[25],[26] A study conducted by Adib-Hajbaghery, et al. in India indicated that the most barriers that hindering them for providing oral care were “too much of writing” followed by “lack of time” and “staff shortage.”[27]

Our finding was in agreement with a study conducted by Ibrahim et al. in Sudan, that no significant correlation existed between ICU nurses experience and their knowledge levels toward oral care[28] and was in contrast with a European study which stated that more experienced the nurses, better is the knowledge, attitude, and practice of oral care.[29]

Our survey categorized the knowledge levels of nurses on a scale of poor, average, satisfactory, and good, surprisingly 83% of them showed satisfactory knowledge. Knowledge levels among the nurses who possessed diploma, graduate, and postgraduate degree showed no significant difference; this insignificance could be due to the use of disproportionate data where the number of postgraduates was only 1% among the total sample of 200 nurses. Lin et al. in Taiwan showed there was no significant correlation between the total scores on knowledge about oral care and the nurses' educational level.[30] These findings were in disagreement with a study conducted by Ibrahim et al.[28]

About 76% of the nurses participated in educative programs quarterly to acquire knowledge on evidence-based oral care standard. Reinforcing proper oral care in education programs, de-sensitizes the nurses to the often-perceived unpleasantness of cleaning oral cavities and prioritizes oral care.[31] Hence, there is a need for large, well-controlled and powered research which can bring strict guidelines bridging the gap between beliefs and practices in treating critically ill patients in ICU.

Limitation of the study

As a questionnaire study, this survey did not consider monitoring VAP. Although a direct relation between VAP and oral health is difficult to substantiate, recent evidence suggest oral care as an important strategy in preventing VAP, hence further research is warranted.


Prevention of hospital-associated infections is advocated as an important objective in critically ill patients; however, little has been determined about the effects of oral care interventions. Evidence-based protocols for oral care are not available, and the oral hygiene methods are generally directed toward patients comfort rather than removal of microbes. Mandatory education of health-care workers can, however, decrease the overall mortality rates and medical care costs.

This survey has emphasized that oral health is important, but a neglected part of nursing and majority of the nurses called for standard oral care protocol.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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